Nokea
The nurse is caring for a client who is receiving blood transfusion therapy. Which clinical manifestations should alert the nurse to a hemolytic transfusion reaction? Select all that apply.
- A. Headache
- B. Tachycardia
- C. Hypertension
- D. Apprehension
- E. Distended neck veins
- F. A sense of impending doom
Correct Answer: A,B,D,F
Rationale: Hemolytic transfusion reactions are caused by blood type or Rh incompatibility. When blood containing antigens different from the client's own antigens is infused, antigen-antibody complexes are formed in the client's blood. These complexes destroy the transfused cells and start inflammatory responses in the client's blood vessel walls and organs. The reaction may include fever and chills or may be life-threatening with disseminated intravascular coagulation and circulatory collapse. Other manifestations include headache, tachycardia, apprehension, a sense of impending doom, chest pain, low back pain, tachypnea, hypotension, and hemoglobinuria. The onset may be immediate or may not occur until subsequent units have been transfused. Distended neck veins are characteristics of circulatory overload.
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The nurse is assessing a 3-day-old preterm neonate with a diagnosis of respiratory distress syndrome (RDS). Which assessment finding indicates that the neonate's respiratory condition is improving?
- A. Edema of the hands and feet
- B. Urine output of 3 mL/kg/hour
- C. Presence of a systolic murmur
- D. Respiratory rate between 60 and 70 breaths per minute
Correct Answer: B
Rationale: RDS is a serious lung disorder caused by immaturity and the inability to produce surfactant, resulting in hypoxia and acidosis. Lung fluid, which occurs in RDS, moves from the lungs into the bloodstream as the condition improves and the alveoli open. This extra fluid circulates to the kidneys, which results in increased voiding. Therefore, normal urination is an early sign that the neonate's respiratory condition is improving (normal urinary output is 2 to 5 mL/kg/hour). Edema of the hands and feet occurs within the first 24 hours after the development of RDS as a result of low protein concentrations, a decrease in colloidal osmotic pressure, and transudation of fluid from the vascular system to the tissues. Systolic murmurs usually indicate the presence of a patent ductus arteriosus, which is a common complication of RDS. Respiratory rates above 60 are indicative of tachypnea, which is a sign of respiratory distress.
A client newly diagnosed with polycystic kidney disease asks the nurse to explain again what the most serious complication of the disorder might be. The nurse will provide the client with information concerning which condition?
- A. Diabetes insipidus
- B. End-stage renal disease (ESRD)
- C. Chronic urinary tract infection (UTI)
- D. Syndrome of inappropriate antidiuretic hormone (SIADH) secretion
Correct Answer: B
Rationale: In polycystic kidney disease, cystic formation and hypertrophy of the kidneys occur. The most serious complication of polycystic kidney disease is ESRD, which is managed with dialysis or transplant. There is no reliable way to predict who will ultimately progress to ESRD. Chronic UTIs are the most common complication because of the altered anatomy of the kidney and from development of resistant strains of bacteria. Diabetes insipidus and SIADH secretion are unrelated disorders.
The nurse teaching an older client about general hygienic measures for foot and nail care should include which instructions? Select all that apply.
- A. Wear knee-high hose to prevent edema.
- B. Soak and wash the feet daily using cool water.
- C. Use commercial removers for corns or calluses.
- D. Use over-the-counter preparations to treat ingrown nails.
- E. Apply lanolin or baby oil if dryness is noted along the feet.
- F. Pat the feet dry thoroughly after washing and dry well between toes.
Correct Answer: E,F
Rationale: The nurse should offer the following guidelines in a general hygienic foot and nail care program: Inspect the feet daily, including the tops and soles of the feet, the heels, and the areas between the toes; wash the feet daily using lukewarm water, and avoid soaks to the feet, thoroughly patting the feet dry and drying well between toes; and avoid cutting corns or calluses or using commercial removers. Additional general hygienic measures include gently rubbing lanolin, baby oil, or corn oil into the skin if dryness is noted along the feet or between the toes; filing the toe nails straight across and square (do not use scissors or clippers); avoiding the use of over-the-counter preparations to treat ingrown toenails and consulting a primary health care provider for these problems; and avoiding wearing elastic stockings (unless prescribed by a health care professional), knee-high hose, or constricting garters.
The nurse teaches a postpartum client about postdelivery lochia. The nurse determines that the education has been effective when the client says that on the second day postpartum, the lochia should be which color?
- A. Red
- B. Pink
- C. White
- D. Yellow
Correct Answer: A
Rationale: The uterus rids itself of the debris that remains after birth through a discharge called lochia, which is classified according to its appearance and contents. Lochia rubra is dark red in color. It occurs from delivery to 3 days postpartum and contains epithelial cells, erythrocytes, leukocytes, shreds of decidua, and occasionally fetal meconium, lanugo, and vernix caseosa. Lochia serosa is a brownish pink discharge that occurs from days 4 to 10. Lochia alba is a white discharge that occurs from days 10 to 14. Lochia should not be yellow or contain large clots; if it does, the cause should be investigated without delay.
The nurse has just administered a purified protein derivative (PPD) tuberculin skin test (Mantoux test) to a client who is at low risk for developing tuberculosis. The nurse determines that the test is positive if which occurs?
- A. An induration of 15 mm
- B. The presence of a wheal
- C. A large area of erythema
- D. Itching at the injection site
Correct Answer: A
Rationale: An induration of 10 mm or more is considered positive for clients in low-risk groups. The presence of a wheal would indicate that the skin test was administered appropriately. Erythema or itching at the site is not indicative of a positive reaction.